Successes Challenges and Opportunities

The combination of national and regional vascular access initiatives supported by new medical technologies has successfully increased national AV fistula prevalence from 26% in December 1998 to 33% in December 2002 and 42.9% in June 2006. Regionally, AV fistula rates range from 37.1% in Virginia and Maryland (ESRD network 5) to 59.5% in the Pacific Northwest (ESRD network 16) [11, 17]. During the same period, catheter use has increase from 19% in December 1998 to 27% in December 2002 and remained at 27% in December 2004 [17]. Although programs to increase fistula prevalence do not necessarily increase catheter use, they can unless combined with concerted catheter reduction efforts. Currently, there is no routine coverage for chronic kidney disease (CKD) care and few CKD programs. These programs increase permanent access placement and decrease catheter use surrounding dialysis initiation. In the US, most patients require placement of a central venous catheter for dialysis initiation. Even in regions that have high AV fistula placement rates it often takes a prolonged period of time before the fistula is placed after dialysis initiation. Patients are frequently discharged with plans for referral to a surgeon for AV fistula placement at a later date. Once patients en ter an outpatient dialysis unit they are often reluctant to proceed with AV fistula or AV graft placement. Fear of needles, disfigurement, body image, increased length of time for post-dialysis hemostasis, illusions about the availability of transplant and depression, all present potential obstacles to fistula placement. In addition, the advent of ESRD and dialysis initiation frequently places patients and families under severe financial stress. Co-pay requirements may present a significant barrier to further procedures or hospitalization, especially in patients with commercial coverage. Payment restrictions can be a disincentive for providers. In some Medicaid programs, additional payment for access placement is unavailable during the initial admission for dialysis initiation [22]. Following fistula placement, approximately one third of patients will need a secondary procedure to allow proper maturation [15]. During this time patients are dialyzed with cuffed catheters with the attendant increased risk of infection, sepsis and potential death. Changing medical technology may also present new opportunities and challenges. If catheter flush solutions, exit site treatments or new impregnated catheters that prevent bacteremia are proven and become available; catheters may become a more viable alternative. Similarly, medications that prevent thrombosis and the development of pseudo-intimal hyperplasia could lead to a resurgence of PTFE grafts. These rapid technologic changes are difficult to predict and assimilate in guidelines, regulations, payment systems and quality improvement programs.

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